|
PM-r
<br /> IN51'RUC)IONS IT)k COMPLIT17ING FORM 'A'
<br /> GENERAL INSIRUCITONS:
<br /> L One FORM "A" shall be completed for all NEW PERMII'S, PUARMf I' 01ANGES or any t?x,%cuxry/srir
<br /> INFORM/V11ON CHANOBS.
<br /> 2- SUBMIT'ONLY ONE(1) FORM *A* for a Facility;/Site, regardless of the number of tanks lo,-aiod at th-, sit,
<br /> 3. This form should be completed by either the PEITUN11TAPP11CANI'or the I OCAI A(;I,',N(,Y UND Rot-ND
<br /> TANK INSPIXN'0IZ-
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument, you are making 3 copies.
<br /> TOP' OF FORM: "MARK ONLY ONE rI`EM"
<br /> Mark an (X) in the box next to the itdm that best describes the reason the form is beino completed.
<br /> L FACILTI-Y/SnT, IWORMA'XION & ADDRENS(MU517\,3E. COMPUTIED)
<br /> I.- Record name and address; (physical location) of the underground tank(s).
<br /> NOTEH: Address MUST have a valid physical location including city, state, and zip code.
<br /> P.O. BOX NUMBERS ARE NOT AMMABLE,
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location,
<br /> 3, Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.)
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> S. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked
<br /> 6. Indicate the NUMBER of'TANKS at this SITE.
<br /> 7. Record the E.P.A. 11) # or write "NONE" in the space provided.
<br /> 11. PROPERTY OWNER INFO TION&ADDRITISS (MUST. BE COMPIP11.11))
<br /> Complete all items in this section, unless all items are the same as SECTION 1: if the same, write 'SAME.AS SI'll' across
<br /> this section. Be sure to check PROPERTY OWNERSHIP TYPE box.
<br /> TIL TANK OWNER INFORMA-11ON & ADDRESS (MUSI'BE COMPLETED)
<br /> Complete all items in this section, unless all items are the same as SE(71ON 1; If the same, write "SAME. AS '-WIE* across
<br /> this section. Be sure to check'TAMC OWNF-,RSIHP'rWF box,
<br /> IV. BOARD OF EQUAL17AIlON U5I'S*1y0RAGE FEE ACCOUNT NUMBER(MUST BE COMOUrnm)
<br /> Enter your Board of Equalization (BOE) USF storage fee account number which is required before your permit application
<br /> can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the
<br /> $0,006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE will code persons exempt from
<br /> paying the storage fee so returns will not be sent. If you do not have an account number with the B014 or if you have any
<br /> questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following addrms:
<br /> Board of Equalization. Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 9,1279-0001,
<br /> V. Pfrl'ROLEUM UST FINANCIAL RE-SPONSI[BUXIT (MUST BE COMPLUMD)
<br /> Identify the method(s)'used by the owner and/or operator in meeting the Federal and State financial responsibility
<br /> requirements. USTs owned by any Federal or State agency are exempt from this requirement.
<br /> VL LEGAL NOTIFICATIONAND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for 130111 LEGAL ANO B111ING NO11FICATTONS,
<br /> APPI.JCANT MUST SIGN AND DAIM111F,FORM AS INDICS1,10.
<br /> IN,5rRU(7QON FOR 111E LOCAL AGENCIES
<br /> 1�tlte,i.),arty and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The
<br /> foi ,,*number may be assigned by the local agency; however, this number must be numerical and cannot contain anv
<br /> [j#Njetical. If the local agency prefers the State Board to assign the facility number, please leave it blank-,
<br /> 11 ARE RVISPOW1311YI-Y OF-HIE LOCAL 11ACHTI-Y -1-0 VERWY -11113
<br /> ACCURACY OF INFORMA7.110N. TIIIS APPLICA110N CANNO`FBF1 PROCL-SSFI) 11"Fill," 1401'. ACCOUNT
<br /> NUMBER IS N(Yl' l,QJ,ED IN. 'ITIT, 1f3CAL AGCOYIS Rt!NPONSIBIlz FOR1111' COWILI-IHONN 01"11W
<br /> "LOCAL AGENCY USE ONLY' INFORMATION 14OX AND FOR FORWARDING ONEFOWN! "A" AND
<br /> ASSOCIA1171) FORM TO -111F MAILOW[Iqu ADDitUss,
<br /> STKIE OF CALIFORNIA.
<br /> 1;1WI13 WAXER RESOURCES CX)NFROL BOARD
<br /> C/O &Wx-nps.
<br /> DATA PROCE&SING 0W11-:1Z
<br /> P.O. BOX 527
<br /> PARAMOUNT, CA 90723
<br />
|